The economic burden of Alzheimer's disease care

The relationship between severity of physical impairment and costs of care in an elderly population

The cost-effective use of long-term care options in a resource-scarce environment depends on targeting services to people who could be cared for most efficiently in specific settings. This study identified subgroups with a high potential for reduced costs of care in different settings by using some measures of physical impairment. The findings indicated that, for elderly people with physical impairment scores below 12 (possible range of 0 to 14), the cost of care was lower with home care than in the nursing home setting. However, for elderly people with physical impairment scores above 12, the cost of care was higher with home care than in a nursing home.

Culture, Economics, and Alzheimer's Disease: Social Determinants of Resource Allocation

Although the United States and the Czech Republic have approximately the same proportion of people older than ages 65 and 80, there are striking differences in the response to Alzheimer's disease. In the United States, there is considerable public interest, openness about the problem, and a vigorous research effort to cope with the disease. In the Czech Republic, by contrast, there is little government, media, or public interest. The disease is treated as a natural result of aging and thought to be a matter offate and acceptance rather than calling for a medical response. The cultural and historical reasons for this difference are explored, noting that a change in Czech attitudes and practices, important and necessary, will nonetheless come at a price. Both coun tries will in the future face new and daunting problems in caring for those with the disease.

Assistance from family members, friends, paid care givers, and volunteers in the care of terminally ill patients

BACKGROUND

In addition to medical care, dying patients often need many types of assistance, including help with transportation, nursing care, homemaking services, and personal care. We interviewed terminally ill adults and their care givers in six randomly selected areas of the United States (five metropolitan areas and one rural county) to determine how their needs for assistance were met and the frequency with which they received such assistance from family members and paid and volunteer care givers.

METHODS

The patients, whose physicians estimated them to have less than six months to live and who had clinically significant illness other than human immunodeficiency virus infection or the acquired immunodeficiency syndrome, were referred to the study by their physicians. Of the 1131 eligible patients, 988 (87.4 percent) consented to a detailed in-person interview conducted in English, as did 893 of the 915 eligible primary care givers (97.6 percent).

RESULTS

Of the 988 terminally ill patients, 59.4 percent were over the age of 65 years, and 51.5 percent were women. The most frequent terminal illness was cancer (in 51.8 percent of the patients), followed by heart disease (18.0 percent) and chronic obstructive pulmonary disease (10.9 percent). Four percent of the patients were in an institution, such as a nursing home, residential hospice, or hospital; the rest were living in a private residence. A need for assistance was reported by 86.8 percent of the patients; they required help with transportation (reported by 62.0 percent), homemaking services (55.2 percent), nursing care (28.7 percent), and personal care (26.0 percent). Of the care givers, 72.1 percent were women. Primary care givers were family members in 96.0 percent of cases; only 4.0 percent were unrelated. Most patients relied completely on family members and friends for assistance. A total of 15.5 percent of patients relied only on paid assistance for more than half of the types of care that they needed. Volunteers (that is, unpaid helpers who were not family members or friends) provided less than 3 percent of all care.

CONCLUSIONS

In our survey of terminally ill patients, family members, usually women, provided the majority of assistance with nonmedical care. Although many people received assistance from paid care givers, very few had assistance from volunteers.

The personal and social consequences of Alzheimer disease

Alzheimer disease (AD) has a drastic effect on the lives of those affected by the disease. Surprisingly little research has studied the personal and social consequences for AD patients. Many appear to go through six stages of change as the disease progresses, but any individual's path through the disease may vary substantially. AD also has a drastic effect on family members who serve as caregivers for people with the disease. These effects are much more studied and better documented. The burdens and, in some cases, benefits of the caregiver role differ from person to person. Race and ethnicity are among the variables that seem to play a role in the caregiver's response. The economic costs of AD are considerable, both for "formal" services, paid for in the money economy, and "informal" services, provided without monetary payment. The direct costs, both formal and informal, are largely, but not entirely, borne by the patient and the patient's family. The overall costs to society clearly amount to scores of billions of dollars.

Misclassification and selection bias when identifying Alzheimer's disease solely from Medicare claims records

BACKGROUND

Medicare claims as the basis for health condition adjustments is becoming a method of choice in capitation reimbursement. A recent study has found that claims-based beneficiary classification for Alzheimer's disease produces lower prevalence estimates and higher average costs than previous healthcare cost studies in this population. These sets of studies differ in data sources, period length, and in their specification of dementia.

OBJECTIVES

Participants in the Medicare Alzheimer's Disease Demonstration (MADDE) provide a sample of persons known to have some form of dementia. This group is used to test the adequacy of claims data for identifying eligible cases and any bias in expenditure differences between those flagged or not flagged by a claim in a given period.

DESIGN

A prospective cohort design using up to 36 months of claims data.

SETTING

The demonstration enrolled 4166 participants in treatment, and 3942 in a control group in eight communities across the US. Cases were combined in this analysis.

PARTICIPANTS

Persons with available Medicare Part A & B claims data: those receiving care under fee for service reimbursement were used in the analysis. A total of 5379 MADDE cases received fee for service care during 1991 and 1992, the period of primary interest in the analysis.

MEASUREMENT

Client health and functional status interviews and Medicare Part A & B claims.

RESULTS

Less than 20% of MADDE participants were classified with Dementia of the Alzheimer type (DAT) from a single year of claims although 68% had a DAT diagnosis from a referring physician. Annualized expenditures were 1.7 times higher among those with DAT from claims compared with those known otherwise to have dementia but who had not been identified with this condition from Medicare claims.

CONCLUSION

Underclassification of dementia from claims records can be partially remedied by increasing the period during which claims are compiled, but additional diagnostic sources will likely be needed to increase prevalence counts closer to 100% of true cases. Risk adjustment based on a single year of reported claims expenditures may overpay providers, at least in the short term, because payment incentives will likely increase prevalence reporting.

Future scenarios for the prevention and delay of Alzheimer disease onset in high-risk groups. An ethical perspective

CONTEXT

Alzheimer disease (AD) presents a major scientific and social challenge in our aging society. Strategies to prevent or delay onset of symptoms, as well as to prevent the decline into the advanced stage, are urgently needed. While these strategies do not yet exist in a proven and clinically applicable form, the science is progressing rapidly.

OBJECTIVES

The pre-eminent goal is to identify asymptomatic persons at high risk for AD and to then apply pharmacologic and lifestyle interventions that delay onset of disease. In this scenario, genetic susceptibility testing may eventually prove accurate enough to be of use in identifying at-risk individuals decades before probable onset, allowing maximal preventive efforts. Second, an important goal is to delay or prevent the onset of moderate and advanced AD through applying compounds that slow the progression of disease, thereby allowing patients to die of unrelated ailments of old age before they lose their capacities to recognize loved ones and to communicate by speech.

CONCLUSIONS

This article provides a discussion of these strategies with attention to a variety of ethical issues that should be of concern to physicians and caregivers. An assessment of the scientific evidence for preventing or delaying AD should be coupled with values analysis.

Health utilities in Alzheimer's disease: a cross-sectional study of patients and caregivers

OBJECTIVES

Although the broad impacts of Alzheimer's disease (AD) are increasingly recognized, little work has focused on the overall health-related quality of life experienced by Alzheimer's disease patients and their caregivers. The study had two main objectives: (1) to test the feasibility of measuring health utilities in Alzheimer's disease with a generic preference-weighted instrument using proxy respondents and (2) to assess the utility scores of Alzheimer's disease patients (and their caregivers) in different disease stages and care setting.

METHODS

A cross-sectional study of 679 Alzheimer's disease patient/caregiver pairs was conducted at 13 sites in the United States: four academic medical centers, four managed care plans, two assisted living facilities, and three nursing homes. The Health Utilities Index Mark II (HUI:2) questionnaire was administered to caregivers of patients who responded both as proxies for patients and for themselves. Responses to the questionnaire were converted into a global utility score, between 0 and 1, using the HUI:2 multi-attribute utility function.

RESULTS

Global utility scores varied considerably across patients' Alzheimer's disease stage: for the six stages assessed (questionable, mild, moderate, severe, profound, and terminal), mean utility scores were 0.73, 0.69, 0.53, 0.38, 0.27, and 0.14, respectively. In multiple regression analyses, Alzheimer's disease stage was a negative and significant predictor of utility scores for patients; setting did not exert an independent effect. Utility scores for the caregivers were insensitive to patients' Alzheimer's disease stage and setting.

CONCLUSIONS

Patients' Alzheimer's disease stage had a substantial influence on health utilities, as measured by the HUI:2. More research is needed to assess the validity of using proxy respondents.

Alzheimer's disease care: costs and potential savings

A cross-sectional study of 679 Alzheimer's disease patients from thirteen sites in nine states provides a unique opportunity to estimate costs of Alzheimer's disease care by disease stage and care setting and to explore potential areas of cost savings. In 1996 annual costs of caring for patients with mild, moderate, and severe Alzheimer's disease were $18,408, $30,096, and $36,132, respectively. Monthly savings of $2,029 in formal services are possible if disease progression can be slowed. Annual institutional cost savings of $9,132 also are achievable if alternative residential settings are used.

Projections of Alzheimer's disease in the United States and the public health impact of delaying disease onset

OBJECTIVES

The goal of this study was to project the future prevalence and incidence of Alzheimer's disease in the United States and the potential impact of interventions to delay disease onset.

METHODS

The numbers of individuals in the United States with Alzheimer's disease and the numbers of newly diagnosed cases that can be expected over the next 50 years were estimated from a model that used age-specific incidence rates summarized from several epidemiological studies, US mortality rates, and US Bureau of the Census projections.

RESULTS

in 1997, the prevalence of Alzheimer's disease in the United States was 2.32 million (range: 1.09 to 4.58 million); of these individuals, 68% were female. It is projected that the prevalence will nearly quadruple in the next 50 years, by which time approximately 1 in 45 Americans will be afflicted with the disease. Currently, the annual number of new incident cases in 360,000. If interventions could delay onset of the disease by 2 years, after 50 years there would be nearly 2 million fewer cases than projected; if onset could be delayed by 1 year, there would be nearly 800,000 fewer prevalent cases.

CONCLUSIONS

As the US population ages, Alzheimer's disease will become an enormous public health problem. interventions that could delay disease onset even modestly would have a major public health impact.

The economic consequences of Alzheimer's disease in the context of new drug developments

The first national symptomatic treatment for Alzheimer's disease has received a very mixed and perhaps ageist reception from purchasers of health care in the UK. This is largely because detailed information on the long-term effects of this class of drugs is scarce. However, by looking at the published evidence on the economic burden of Alzheimer's disease, some observations and assumptions can be made as to the influence of the new drug treatments. The drug therapies available and those most likely to become licensed are reviewed and the potential economic impact is discussed. Long-term outcome studies would properly address this, but as these drugs have now demonstrated efficacy, particularly in non-cognitive behaviours, it will be ethically more difficult to maintain patients on placebo for long periods. Some assumptions therefore have to be made from long-term open-label studies. Those drugs currently available, and those in development, may offer effective treatment for some of the core symptoms of Alzheimer's disease, slowing the rate of cognitive decline and preserving competence in activities of daily living for longer. If handled correctly, these treatments have the potential to offer cost savings for many patients, and cost-effectiveness improvements look probable.

The formal mental health care burden among recently deinstitutionalized patients

This article examines the extent to which the costs of formal health care are shifted from third-party payers to the patient and his or her family, especially during the transition to the community after discharge from a state hospital. Findings indicate that patients residing in the community are as likely to receive some care as their counterparts in institutions, but are at higher risk for uncovered care. Uncovered care is more likely to manifest as an unmet need for patients who have been recently discharged, especially for racial minorities, and as an out-of-pocket expense for patients who are established in the community.

An economic evaluation of donepezil in the treatment of Alzheimer's disease

Using data from a longitudinal survey of caregivers of Alzheimer's disease patients, we calculated the average per-patient direct medical costs over a 6-month period for a matched sample of patients (N = 376). A group of patients receiving donepezil for 6 months was compared with a group not receiving this form of drug therapy. The groups were matched by disease severity, age, sex, and comorbidity. The average age in the two groups was 74 years, with 50% female and 90% white. Patients in both groups had a mean of 1.6 comorbid conditions. No patients in either group were institutionalized at the beginning of the 6-month period, and all patients were taking at least one prescription drug, including donepezil. Mean 6-month direct medical expenses for a patient receiving donepezil were $3443, including the cost of the drug, whereas the per-patient mean expenses for the comparison group were $3476. Although the patients receiving donepezil had greater expenditures for prescription drugs, these costs were offset by a slower rate of institutionalization. At the end of the 6-month period, 5% of donepezil patients were institutionalized, compared with 10% of the nondonepezil patients. The cost of receiving donepezil treatment for 6 months did not result in a significantly higher per-patient mean direct cost.

Structural and kinetic features of amyloid beta-protein fibrillogenesis

Alzheimer's disease (AD) is an archetype of a class of diseases characterized by abnormal protein deposition. In each case, deposition manifests itself in the form of amyloid deposits composed of fibrils of otherwise normal, soluble proteins or peptides. An ever-increasing body of genetic, physiologic, and biochemical data supports the hypothesis that fibrillogenesis of the amyloid beta-protein is a seminal event in Alzheimer's disease. Inhibiting A beta fibrillogenesis is thus an important strategy for AD therapy. However, before this strategy can be implemented, a mechanistic understanding of the fibrillogenesis process must be achieved and appropriate steps selected as therapeutic targets. Following a brief introduction to AD, I review here the current state of knowledge of A beta fibrillogenesis. Special emphasis is placed on the morphologic, structural, and kinetic aspects of this complex process.

Factors influencing the use of adult day care by individuals with Alzheimer's disease: a multivariate examination of the California Alzheimer's Disease Diagnostic and Treatment Center Program

Longitudinal data from the California State Alzheimer's Disease Diagnostic and Treatment Center Program (ADDTC) are analyzed to determine what factors, including ADDTC staff recommendations for service use, influence utilization of adult day care services by individuals with Alzheimer's disease. The records of 737 clients are examined from 1988 to 1992 to determine predictors of client service utilization (including client predisposing, enabling, and need characteristics; caregiver characteristics; and community characteristics). Results of logistic regression analyses indicate that ADDTC staff recommendations and previous use of adult day care services are significantly related to use of adult day care services. Other client predisposing, enabling, and need characteristics; caregiver characteristics; and community characteristics were not significantly related to service use.

Cost-of-illness of scleroderma: the case for rare diseases

OBJECTIVE

To determine the societal costs of scleroderma (SSc), a rare chronic connective tissue disease that affects approximately 98,000 Americans. Lack of reliable national databases limit rare disease cost studies, and this study suggests methods of using multiple data sources to assess the costs of rare diseases.

METHODS

Primary and secondary data sources were used to calculate direct and indirect costs of SSc, including discounted lifetime mortality and morbidity costs. A prevalence-based, human capital approach was used. Sensitivity analyses were used to vary parameters that are uncertain, such as prevalence, mortality, and labor costs.

RESULTS

Annual direct and indirect costs of SSc in the United States are $1.5 billion. Morbidity represents the major cost burden, with costs of $819 million (56%) of total costs. The current value of lifetime earnings lost was $179 million (12%) or $300,000 per death. Direct costs were $462 million (32%) or $4,731 per person annually, indicating that costs are spread over the long disease duration.

CONCLUSIONS

This study provides one model for the assessment of rare disease costs. Triangulation of data sources and sensitivity analyses are important for determining the costs of rare diseases. The high cost of SSc, despite its low prevalence, suggests that the burden of rare chronic diseases can be high. The high morbidity costs reflect the young age of onset of the disease as well as the need for treatments to decrease morbidity costs. Local shared databases and national surveys are needed to improve cost estimates of rare diseases.

Service Selection: Concordance Between Alzheimer's Disease Diagnostic and Treatment Center Clients' Choices and Program Staff Recommendations

Service choices of Alzheimer's Disease Diagnostic and Treatment Centers (ADDTC) enrollees (N = 822) and ADDTC professional staff are compared. Results suggest that community- dwelling Alzheimer's patients are not high service consumers, and ADDTC staff generally agree with their service choices. Limited discordance noted pertained to recommended decreases in homemaker chore, senior center, meals, transportation, and home health use; and suggested increases in psychiatric service, case management, and adult day care use. Findings confirm the high degree of informal care of the demented and the reluctance or inability of patients and caregivers to use formal services. Results also indicate that as ADDTC-like programs prolifer ate, long-term care costs may remain unchanged because patients and caregivers may already know what formal care they need and want.

Roadblocks encountered in recruiting patients for a study of sleep disruption in Alzheimer's disease

Recruitment strategies and the roadblocks encountered in a clinical trial are described. A four-group, repeated measures design was used to test the effects of three sleep-related behavioral interventions on sleep disruption and related variables in Alzheimer's disease patients and their primary caregivers. Despite extensive recruitment efforts, enrollment did not meet expectations. Data analysis revealed three types of roadblocks to recruitment: caregiver resistance, provider resistance, and a mismatch of the disease characteristics with protocol requirements. Recommendations are made to help others solve recruitment problems.

The pharmacoeconomics of dementia therapies. Bringing the clinical, research and economic perspectives together

Dementia has reached epidemic proportions. The large numbers of people affected and the major impact that this disease has on healthcare costs are still not fully appreciated by the general public, governments or healthcare providers. Prevalence rates are expected to continue to escalate because of the dramatic aging of the population in many nations. This could create serious economic problems for already strained healthcare systems around the world. Fortunately, medications suitable for widespread use appear to be on the horizon. As therapies are developed, it will be necessary to assess their impact on individuals, healthcare systems and societies. The latter two refer to pharmacoeconomic research, an area in which a careful examination of issues central to the design and interpretation of such analyses must now be undertaken. This article outlines the critical components in the application of pharmacoeconomic methodology to the field of dementia research. Specifically, the accuracy of a pharmacoeconomic study is affected by the prevalence data and the economic methodology used. The outcome measures used in efficacy, effectiveness and pharmacoeconomic studies must be carefully chosen to ensure that they are valid, reliable and sensitive to change. These measures must also be meaningful to patients, families and clinicians. In the future, dementia therapies may prevent, delay, cure or slow the progression of the disease, and may also help control symptoms. It is important to study the impact of these effects from the perspectives of the patient, family and society. Dementias are important in terms of the number of people affected and the degree of suffering experienced, as well as the considerable financial burdens placed on families and society. Pharmacoeconomic analyses will have a significant influence on healthcare decisions affecting people with dementia. To ensure that these future decisions are in the best interests of patients, families and society, clinical knowledge of dementias must be incorporated into the design of pharmacoeconomic studies. Collaboration between clinicians, researchers and economists is essential in assessing future pharmacotherapies for dementing illnesses.

The economic impact of the tacrine in the treatment of Alzheimer's disease

Alzheimer's disease is a progressive neurodegenerative disorder that results in tremendous economic and quality-of-life burdens. This paper presents estimates of the impact of tacrine use on the costs of caring for patients with Alzheimer's disease. This study presents a cost analysis, based on a decision-analytic model constructed around the milestones in the progression of Alzheimer's disease. Clinical data concerning the effectiveness of tacrine came from published results of an open-label follow-up study of 663 patients originally enrolled in a placebo-controlled clinical trial of tacrine. Data concerning longevity, nursing home time, and costs of community and nursing home care are taken from several reports based on prospective cohorts of patients. The use of tacrine was associated with a cost savings of $9,250 (7.5%) over the patient's lifetime from diagnosis to death, even when averaged over data from patients who discontinued tacrine treatment or took only low doses. Most of the savings were due to reduced time in nursing homes. Patients who continued higher doses of tacrine experienced a cost saving of more than $36,500 over 5 years. Model results persisted over a wide range of sensitivity analysis variations. The use of tacrine for patients with mild-to-moderate Alzheimer's disease reduces the costs of medical and social services required for care, and it increases functioning and delays nursing home placement for up to 433 days. New treatments that can both improve clinical outcomes and save costs should be given serious consideration by clinicians and administrators.

The use of home care by cancer patients: a multivariate analysis

The use of home care by cancer patients over the course of a year was analyzed using a two-part model that estimated: (1) the probability of any use, and (2) the quantity of visits given some use. The findings support the use of a two-stage model for estimating home care over single equation approaches. We found that while HMO membership increased the probability of some home care for cancer, it resulted in a smaller number of visits given some use. Health care coverage was also found to have different effects on these two components of total use. Some implications of some of these findings for future policies are discussed.

Dementia: diagnostics, early treatment, and assistance from family members

This state of the art document is the result of the conference held in Stockholm on March 9-10, 1995, initiated by the Swedish Medical Research Council. The conference brought together researchers from basic science and clinic to different disciplines. Response to questions was given in small groups and the answers were presented and discussed with all the participants. The final consensus was formulated in this larger group and comprises the state of the art document.

Caregiver time use: an outcome measure in clinical trial research on Alzheimer's disease

OBJECTIVE

To assess whether unpaid caregiver time and paid professional time increase as cognitive impairment associated with Alzheimer's disease increases and to evaluate the utility of caregiver time as an additional outcome measure in clinical trial research of Alzheimer's disease.

METHODS

This was a 24-week, double-blind, multicenter, parallel-group, placebo-controlled study conducted at 17 clinical outpatient sites by Hoechst-Roussel Pharmaceuticals Inc. A total of 449 patients older than 40 years with probable Alzheimer's disease of mild to moderate severity (criteria of the National Institute for Neurological and Communicative Disorders and Stroke--Alzheimer's Disease and Related Disorders Association) entered the study, and 284 completed both baseline and week 24 data collection. A total of 160 caregivers completed time allocation surveys at baseline and at 24 weeks. Patients with Alzheimer's disease received 150 mg/day and 225 mg/day Velnacrine maleate (parallel-group treatment) and placebo. Cognitive function was measured with use of cognitive and noncognitive subscales of the Alzheimer's Disease Assessment Scale (ADAS). Unpaid caregiver and paid professional time use were measured with use of the Caregiver Activities Time Survey (CATS).

RESULTS

Unpaid caregiver time per day increased significantly with cognitive impairment at baseline as measured by the ADAS cognitive and noncognitive components. Velnacrine therapy significantly improved cognitive function relative to placebo, and this was associated with decreased unpaid caregiving time at trend levels. Specifically, caregivers of patients in the high-dose velnacrine group (225 mg/day) experienced a partial release from their time involvements, especially in the area of patient supervision, by an average of 3.3 hours per day.

CONCLUSIONS

To our knowledge, this study represents the first time that the ADAS has been linked to a caregiver outcome. Results suggest that unpaid caregiver time allocation is sensitive to changes in cognitive function and therefore may be useful as an additional outcome measure in clinical trials of pharmaceutical interventions for Alzheimer's disease.